impact of joint epidemics of HIV and noncommunicable diseases

Millennium Development Goals

Drivers of inequality in millennium development goal progress statistical analysis.

Many low- and middle-income countries are not on track to reach the public health targets set out in the Millennium Development Goals (MDGs). The authors evaluated whether differential progress towards health MDGs was associated with economic development, public health funding (both overall and as percentage of available domestic funds), or health system infrastructure. They also examined the impact of joint epidemics of HIV and noncommunicable diseases, which may limit the ability of households to address child mortality and increase risks of infectious diseases. Stuckler and colleagues calculated each country's distance from its MDG goals for HIV, tuberculosis, and infant and child mortality targets for the year 2005 using the United Nations MDG database for 227 countries from 1990 to the present. They studied the association of economic development (gross domestic product [GDP] per capita in purchasing-power-parity), the relative priority placed on health (health spending as a percentage of GDP), real health spending (health system expenditures in purchasing-power-parity), HIV burden (prevalence rates among ages 15-49 y), and noncommunicable disease burden (age-standardised chronic disease mortality rates), with measures of distance from attainment of health MDGs. To avoid spurious correlations that may exist simply because countries with high disease burdens would be expected to have low MDG progress, and to adjust for potential confounding arising from differences in countries' initial disease burdens, they analysed the variations in rates of change in MDG progress versus expected rates for each country. While economic development, health priority, health spending, and health infrastructure did not explain more than one-fifth of the differences in progress to health MDGs among countries, burdens of HIV and noncommunicable diseases explained more than half of between-country inequalities in child mortality progress (R(2)-infant mortality = 0.57, R(2)-under 5 mortality = 0.54). HIV and noncommunicable disease burdens were also the strongest correlates of unequal progress towards tuberculosis goals (R(2) = 0.57), with noncommunicable diseases having an effect independent of HIV, consistent with micro-level studies of the influence of tobacco and diabetes on tuberculosis risks. Even after correcting for health system variables, initial child mortality, and tuberculosis diseases, the authors found that lower burdens of HIV and noncommunicable diseases were associated with much greater progress towards attainment of child mortality and tuberculosis MDGs than were gains in GDP. An estimated 1% lower HIV prevalence or 10% lower mortality rate from noncommunicable diseases would have a similar impact on progress towards the tuberculosis MDG as an 80% or greater rise in GDP, corresponding to at least a decade of economic growth in low-income countries. Unequal progress in health MDGs in low-income countries appears significantly related to burdens of HIV and noncommunicable diseases in a population, after correcting for potentially confounding socioeconomic, disease burden, political, and health system variables. The common separation between noncommunicable diseases, child mortality, and infectious syndromes among development programs may obscure interrelationships of illness affecting those living in poor households--whether economic (e.g., as money spent on tobacco is lost from child health expenditures) or biological (e.g., as diabetes or HIV enhance the risk of tuberculosis).

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http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000241

Editors’ Note: This thought-provoking article is essential reading for everyone focused on the 8 Millennium Development Goals (MDG), their 21 quantifiable targets, and 60 indicators of progress. It is a first attempt to analyse the determinants of global inequalities in progress toward the health MDGs 4 and 6. The 2015 targets and indicators for the 3 health MDGs are summarised in a box that would be handy on the wall above your desk. Unmet MDG progress in infant, child, and tuberculosis (TB) mortality, as well as HIV prevalence, suggests that fewer than half of low-income countries will achieve the 2015 targets for MDGs 4 and 6. This intriguing analysis of 227 countries found that likely explanatory suspects such as economic development (gross domestic product [GDP]), health spending as a per cent of GDP, and numbers of physicians per capita together explained only one-fifth of the differences in progress on these health MDGs between countries. What is making the difference? Burdens of HIV and non-communicable diseases (NCD) explained more than half of differences in infant mortality progress and were strongly associated with unequal progress on TB. A 1% drop in HIV prevalence or a 10% decline in mortality from non-communicable diseases such as heart disease, diabetes, cancer, tobacco-related lung disease, disabling mental disease, and accidents, would improve a country’s progress on TB as much as if its GDP rose by an unlikely 80%. For child mortality, the magnitude of effect was similar to a 40% rise in GDP. We know the strong links between HIV and TB, HIV and infant mortality, and HIV and under-five child mortality. However, we have underestimated the effects in low-income countries of co-existing epidemics of obesity due to the ‘nutrition transition’, lung disease due to aggressive marketing of tobacco products, and decreased physical activity due to urbanization on achievement of the health MDGs. Since the poorest households often face the greatest burden of non-communicable diseases and HIV, as well as being the most affected by child mortality and TB, we need to investigate these interrelationships and address them explicitly to get on track for 2015.